Reasons for the Low Male Involvement in Routine Child Immunization in Hoima District Uganda using the Attitude, Social Influence and Self Efficacy Model https://ijn-medicalarticles.info/ji/article/296

Abstract

Millions of children continue to miss immunizations each year despite global increases in financing and advances in vaccine technology. Male involvement in routine child immunization activities could improve and sustain coverage but is rarely emphasized in immunization programs or research. This study identified factors associated with male involvement in routine child immunization using the attitude, social influence and self-efficacy model. A household cluster survey was conducted among 460 fathers aged 18 years or more, with children aged 10-23 months. A semi-structured interviewer-administered questionnaire was used to collect data. Prevalence Risk Ratios (PRRs) were used to measure associations with level of involvement using generalized linear models with Poisson family, log link and robust standard errors in STATA 12. Our findings show that half (51%, 236/460) of the respondents were aged 25-34 years; 36% (166/460) had completed eight or more years of formal education. Although 90% (415/460) of the respondents were willing to be involved, only 29% (133/460) were highly involved in routine child immunization. Highly involved fathers had a positive attitude towards involvement in routine child immunization (adj. PRR 2.3, 95% CI 1.18 – 4.98) and were ≥45 years [adjusted prevalence risk ratio (adj. PRR) 2.0, 95% confidence interval (CI) 1.15-3.76]. Traders had a lower involvement compared to those engaged in other occupations (adj. PRR 0.55, 95% CI: 0.37-0.82). In conclusion, few fathers were involved in routine child immunization. Strategies to improve fathers' positive attitude such as health education are needed to increase their involvement, specifically targeting younger fathers and traders.

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JOURNAL OF IMMUNIZATION
ISSN NO: 2577-137X
Research Arcle
Reasons for the Low Male Involvement in Routine Child Immunization in Hoima District Uganda using
the Attitude, Social Influence and Self Efficacy Model
Charles Baguma1, Juliet N. Babirye1,*, Paul Oryema1, Peter Wasswa2, Lynn Atuyambe1
1. School of Public Health, Makerere University College of Health Sciences.
2. African Field Epidemiology Network (AFENET).
Abstract:
Millions of children continue to miss immunizations each year despite global increases in financing and advances
in vaccine technology. Male involvement in routine child immunization activities could improve and sustain
coverage but is rarely emphasized in immunization programs or research. This study identified factors
associated with male involvement in routine child immunization using the attitude, social influence and self -
efficacy model. A household cluster survey was conducted among 460 fathers aged 18 years or more, with
children aged 10-23 months. A semi-structured interviewer-administered questionnaire was used to collect data.
Prevalence Risk Ratios (PRRs) were used to measure associations with level of involvement using generalized
linear models with Poisson family, log link and robust standard errors in STATA 12. Our findings show that half
(51%, 236/460) of the respondents were aged 25-34 years; 36% (166/460) had completed eight or more years
of formal education. Although 90% (415/460) of the respondents were willing to be involved, only 29%
(133/460) were highly involved in routine child immunization. Highly involved fathers had a positive attitude
towards involvement in routine child immunization (adj. PRR 2.3, 95% CI 1.18 – 4.98) and were ≥45 years
[adjusted prevalence risk ratio (adj. PRR) 2.0, 95% confidence interval (CI) 1.15 - 3.76]. Traders had a lower
involvement compared to those engaged in other occupations (adj. PRR 0.55, 95% CI: 0.37 - 0.82). In
conclusion, few fathers were involved in routine child immunization. Strategies to improve fathers’ positive
attitude such as health education are needed to increase their involvement, specifically targeting younger
fathers and traders.
DOI : 10.14302/issn.2577-137X.ji-16-1026
Corresponding author: Juliet N. Babirye, MBChB, MPH, PhD. School of Public Health, Makerere University Col-
lege of Health Sciences, P.O. Box 7072, Kampala Uganda. Telephone: +256 712 468 526,
Email: jnbabirye@yahoo.co.uk
Running Title: Male involvement in routine child immunization Hoima.
Keywords: Male involvement in routine child immunization Hoima.
Received Apr 15, 2016; Accepted Jun 09, 2016; Published Jun 14, 2016;

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Introduction
Nearly 19 million infants worldwide did not
complete their routine immunization schedules in 2014,
more than 60% of these lived in 10 developing countries
including Uganda [1]. This resulted in 1.5 million deaths
due to vaccine preventable diseases (VPDs) and
accounted for about a third of deaths and disabilities
among children under-five years of age in these
countries [1]. Previous studies indicate that individual,
community and health system factors underlie failure to
complete immunization schedules in developing settings
[2-6]. In Uganda, the reasons for high incompletion
(48%) of routine immunization schedules are not well
understood particularly because 10 districts in Western
Uganda, where Hoima is situated, report high access
(98%) to immunization services [7].
Interventions that generate demand for
immunization services in developing countries have
traditionally targeted women neglecting the involvement
of men mainly due to the general belief that women are
typically responsible for child immunization [3, 8].
However, the lack of male involvement has been shown
to reduce immunization uptake, increase dropout, and
un-timely commencement and completion of routine
child vaccination schedules [3, 8, 9]. Paradoxically, male
involvement is particularly emphasized in maternal
health care with little attention to child vaccination, one
of the world’s most cost-effective child survival
strategies [10].
Since the launch of the Global Vaccine Action
Plan for 2011 to 2020 [11], efforts are under way to
strengthen routine immunization to meet vaccination
coverage targets and to introduce new vaccines. The
introduction of new vaccines is in addition to the pre-
existing twelve doses currently provided on the routine
immunization schedule in Uganda which requires several
clinic visits [2]. This will increase demands on the
already overburdened mothers, and without high male
involvement this may be difficult to achieve [3, 9]. This
study used the attitude, social influence and self-efficacy
(ASE) model to identify factors associated with male
involvement in routine child immunization among fathers
in Hoima, Uganda so as to inform implementation of
strategies for increased utilization of routine child
immunization.
Materials and Methods
Study Design and Setting
We conducted a household cluster survey in
Hoima district, Western Uganda, between March and
May, 2013. Hoima District is located 230km West of
Kampala, the Capital City of Uganda. Hoima had a total
population of 549,000 people, 106,000 of whom were
aged under-five and 22,000 were infants. The annual
population growth rate is 4.7% [12], with an infant
mortality rate of 85/1000 and under-five mortality of
88/1000 live births [7]. Hoima has 54 functional health
facilities (45 public, 7 Private Not for Profit (PNFP) and 2
Private for Profit (PFP) facilities) and all provide routine
child immunization (RCI) services [12].
Eligibility and Sampling
Fathers who were at least 18 years old with
children aged 10 to 23 months, and had lived in Hoima
for at least a year prior to the survey were included in
the study. The required sample size was 460 men using
the formula by Bennett for sampling in cluster surveys,
with the following assumptions; a two-sided test with a
precision of 0.03, 80% power, 10 households per
cluster, intra-cluster correlation of 0.1, and a design
effect of 1.9 and 50% level of male involvement in
routine child immunization [13].
Multistage cluster sampling method was used to
select study participants. In the first stage, five of 13
sub-counties in Hoima district were randomly selected
using computer generated random numbers. In the
second stage, two parishes from each of the five
selected sub-counties were randomly selected (ten

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parishes in total). In the third stage, a list of all villages
from each of the ten parishes was generated. A total of
46 out of 116 villages were then selected proportionate
to the number of villages in each parish. Villages (lowest
administrative units) were considered as clusters in this
study. At the last stage, households were consecutively
searched for eligible fathers. Ten fathers were
interviewed in each village, selecting one respondent
per household.
In each of the selected villages, a random
starting point preferably a main junction in the village
was identified. Then beginning with the house on the
eastern side, data collectors moved from house to house
looking for eligible respondents until the desired sample
for the village was obtained.
In case a household did not have an eligible
respondent, the respondent declined to participate, or
was not at home at the time the house was approached
for study inclusion, the next household was considered.
In a household with an eligible man with more than one
child aged 10-23 months or a polygamous man with
partners each having a child in the 10-23 months age
group; the male partner would be interviewed in
reference to the youngest child in the age group. This
last criterion was chosen to reduce recall bias for the
study outcome.
The Attitude, Social Influence and Self-Efficacy
(ASE) Model
The ASE model was originally developed for
smoking cessation by de Vries et al [14], and has been
widely applied in explaining health behavior [3, 15, 16].
We used the ASE model in this study because it not only
considers social influence and self-efficacy as predictors
of behavior but it is also better suited to explaining
current behavior; unlike the health belief and the trans-
theoretical models that do not consider social influence
as a predictor of behavior, and trans-theoretical model
that is much more focused on promoting change in
behavior [17].
As shown in figure 1, behavior related to male
involvement in RCI is a result of behavior intention. This
is in turn is influenced by three main factors; attitude,
social influence and self-efficacy. Attitude is an
individual’s evaluation of merits and demerits of
involvement in routine child immunization services.
Social influence results from social norms in regard to
male involvement in routine child immunization. It’s
Fig. 1 Attitude-Social Influence-Self-efficacy Model.

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influenced by gender roles, and support, or
discouragement from significant others such as one’s
parents and spouse [18, 19]. Self-efficacy is the
perceived ability to perform a behavior, and to cope with
barriers to perform a behavior. It influences both
behavior intention and behavior itself. Self-efficacy may
be influenced by a man's perceived benefits of their
involvement in routine child immunization. Barriers and
abilities could influence male partner involvement in RCI.
Previous behavior or trying to perform the behavior has
a feedback mechanism that in turn influences the
attitude, social influence and self-efficacy. Demographic
characteristics on the other hand are unchangeable but
useful in identifying men less supportive of their
partners in routinely immunizing their children so they
can be targeted [3].
Data Collection and Measurements
The measurements used in this study were
based on the ASE model described above. Data were
collected through face-to-face interviews using a pre-
tested structured questionnaire that was translated into
Runyoro (local dialect) and back translated into English
for consistence in meaning. We describe below the
measurements used for this study; male involvement in
routine child immunization, attitude, social influence and
self-efficacy.
Male Involvement in Routine Child Immunization
This was estimated based on an involvement
index developed from five indicators: 1) if the male
partner had taken their child for routine immunization,
2) had accompanied the partner for routine child
immunization, 3) provided financial support for a child’s
routine immunization visits, 4) discussed with the
partner about the child’s immunization schedule, and 5)
had participated in making a decision with partner to
have a child immunized. Each indicator had an equal
weight score of one. The involvement score of each
respondent ranged from 0=no involvement to
5=involved in all five areas at least once. A total score of
at least 4 was considered as high male involvement and
≤3 as low male involvement [20].
Attitude:
A male partners' attitude was defined as his
evaluation of merits and demerits of his involvement in
routine child immunization (RCI) [3, 15]. The man’s
attitude towards involvement in RCI was measured on
an ordinal scale using a four- point likert item
(3=Strongly agree, 2=Agree 1=Disagree, 0=Strongly
disagree) using the following four statements: 1) routine
child immunization care is equally a man’s role, 2) male
involvement in routine child immunization is beneficial,
3) I am willing to be involved in routine child
immunization, and 4) I can encourage another man to
be involved in a child’s routine immunization. A binary
variable (agree/disagree) was then created from the
likert scale for each statement and a score of one was
assigned to each statement agreed to. If a respondent
scored a maximum of ≥3 points then they would be
categorized as having a positive attitude and those who
scored ≤2 points were regarded as having a negative
attitude towards male involvement in RCI.
Social Influence:
Social influence was described as resulting from
social norms in regard to male involvement in routine
child immunization [3, 15]. In this study, social influence
was assessed using three key questions: 1) who is
mainly responsible for ensuring that a child is immunized
in this community? 2) have you ever been encouraged
by significant others like your spouse or parent to be
involved in RCI? 3) Have you ever been discouraged by
significant others like your spouse or parents from being
involved in RCI? [21]
Self-Efficacy:
Self-efficacy was defined as a father’s perceived
ability to cope with barriers to their involvement in RCI
[2, 3, 15]. Fathers were asked if they felt they were able
to cope with or overcome the following major barriers to
participate in routine child immunization: competing
work demands, gender role rigidities, peer disapproval,

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financial constraints; long distance to, and long waiting
time at the health facility. Again, a 4-point likert scale
was used here (4=most likely, 3=likely, 2=less likely,
1=not likely). Respondents who responded “most likely”
or “likely” to overcome to four of the challenges were
categorized as having high self-efficacy and those who
responded similarly to ≤3 of the challenges were
classified as having low self-efficacy.
Data Analysis
Data were coded, entered, cleaned and analyzed
using STATA version 12.0. We computed prevalence risk
ratios (PRR) as a measure of association between the
outcome and independent factors (attitudinal, social
influence and self-efficacy factors) using generalized
linear model (GLM) with Poisson family and a log link
with robust standard errors [22]. Univariable then
multivariable analysis were conducted. All factors with p
<0.15 at univariable analysis and factors plausibly
associated with the primary outcome were entered in
multivariable GLM models to obtain adjusted prevalence
risk ratios (adj.PRR). Two multivariable models were
used in this study; in the first multivariable GLM,
background characteristics and the specific variables
that were used to create overall attitude, social influence
and overall self-efficacy were run. In the second GLM
model, the background characteristics, overall attitude,
overall social influence and overall self-efficacy were
run. A stepwise backward elimination approach in each
of the two models was used to ascertain the best fitting
model with a log likelihood tending towards zero.
Ethical Considerations
Ethics approval was obtained from Makerere
University School of Public Health Higher Degrees
Research and Ethics Committee. Interviews were
conducted only when written informed consent had been
obtained from the study participants.
Results
A total of 460 eligible respondents were
approached for study inclusion and all were interviewed,
representing 100% response rate. Respondents were
aged between 18-72 years with a mean age of 32.3
years (SD=8.7). Half (51%, 236/460) of them were
aged 25-34 years and only 36% (166/460) had
completed 8 or more years of formal education. Most
(77%, 353/460) respondents had four or less children,
were in monogamous relationships (83%, 380/460);
41% (190/460) were peasant farmers, and 29%
(135/460) were traders, table 1.
Level of Male Involvement:
Overall, 29% (132/460) of all respondents were
highly involved in routine child immunization (RCI). The
level of involvement varied by activity; for instance,
most (76.1%, 350/460) respondents reported provision
of financial support for the child’s routine immunization
session(s), followed by accompanying the partner
(61.5%, 283/460), discussing a child’s routine
vaccination schedule with partner (57.8%, 266/460),
and least involvement (18%, 84/460) was in taking their
children for routine immunization, table 2.
Attitude:
Overall, 87% (399/460) of respondents had a
positive attitude towards involvement in RCI (Cronbach’s
alpha correlation coefficient (α) = 0.8). The majority
(87%, 401/460) agreed that male involvement in RCI
was beneficial in terms of: sharing parental responsibility
(60%, 275/460), showing love to partner (40%,
186/460), opportunity to receive child care education as
a couple at immunization clinic (15%, 69/460), and help
both parents plan and be better prepared for the next
visit (9%, 42/460), and improve timely completion of
routine child immunization schedule (12%, 55/460).
Nearly all (90%, 415/460) respondents were willing to
be involved in RCI and to encourage other men to be
involved in RCI (88%, 405/460).
Social Influence:
Most (73%, 334/460) respondents reported that
it is mainly a woman’s responsibility to have a child
immunized and only 3% (14/460) said it was mainly a
man’s role. In terms of the key roles fathers thought

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Variable
Frequency
(n=460) Percentage (%)
Age of the respondent
18-24 74 16.1
25-34 236 51.3
35-44 98 21.3
≥45 years 52 11.3
Formal educational Level
≤7 years 236 51.3
>7 years 224 48.7
Marital Status
Living with partner 299 65
Married 142 31
Separated 19 4
Type of marriage
Monogamous 380 83
Polygamous 78 17
Household size
≤5 People 308 67
>5 People 152 33
Occupation
Peasant farmer 190 41.3
Casual laborer 83 18
Trader 135 29.4
Formally employed 52 11.3
Religion
Anglican 184 40
Catholic 155 33.7
Muslim 59 12.8
Other 62 13.5
Number of children
≤4 353 76.7
>4 107 23.3
Age of child in months
<12 69 15
12-17 232 50
18-23 159 35
Sex of the child
Male 222 48
Female 238 52
Table 1: Respondent and child characteristics

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other community members expected of them in RCI,
21% (95/460) reported taking the child for
immunization, 34% (155/460) reminding partner of next
visit and 45% (209/460) reported providing financial
support.
Most men (68%, 313/460) reported
encouragement for involvement in RCI mainly from their
spouses (28%, 129/460). Respondents reported that
other community members considered the act of male
involvement in RCI as an expression of love for the wife
and child (23%, 107/406), and as a way of a father
showing a sense of responsibility for his family (50%,
230/460).
On the other hand; 23% (106/460) of
respondents reported discouragement from involvement
in RCI mainly from their peers (22%, 101/460). Their
involvement was viewed by other community members
as a sign of “weakness” for a man (34%, 157/460) and
as having time to waste (4%, 19/460).
Self-Efficacy:
Overall, most (72%, 333/460) respondents had
a high self-efficacy towards involvement in RCI
(Cronbach’s alpha correlation coefficient (α) = 0.83).
Key barriers to male involvement in routine child
immunization (RCI) were: competing work demands
(88.7%, 408/460), long waiting time at immunization
clinics (43.3%, 199/460), considering routine child
immunization as a woman’s responsibility (38.9%,
179/460), financial constraints (24.4%, 112/460), long
distance to immunization facility (17.6%, 81/460), and
perceived ridicule from peers (5.7%, 26/460). Nearly all
fathers (90%, 395/460) expressed ability to cope with or
overcome financial constraints; 79% (362/460) with long
distance to immunization clinic; 76% (348/460) with
ridicule from peers; 70% (321/460) with traditional
gender roles, 67% (306/460) with competing work
demands; and 56% (258/460) with long waiting time at
immunization clinic.
Independent Predictors
Both univariable and multivariable level analyses
are shown in table 3. At multivariable analysis high
male involvement in RCI was significantly associated
with; men who were 45 years or older (adj. PRR 2.0,
95% CI 1.15 - 3.76), and men who had a positive
attitude towards involvement in RCI (adj. PRR 2.3, 95%
CI 1.18 – 4.98). Low Male involvement in RCI was
observed among men whose main occupation was
trading (adj. PRR 0.55, 95% CI 0.37 - 0.82). Male
education level, perceived self-efficacy, and social
influence towards involvement in RCI were not
significantly associated with male involvement in RCI,
table 3.
Discussion
This study identified factors associated with
male involvement in routine child immunization (RCI).
We found that, although 90% of men were willing to
participate in RCI, only 29% were highly involved. High
male involvement in RCI was more often among
respondents that were 45 years or older and among
Involvement indices
Yes No
no. (%) no. (%)
1. Did you ever take the child yourself for routine immunization? 84 (18.3) 376 (81.7)
2. Did you ever accompany your partner for routine child immunization? 283 (61.5) 177 (38.5)
3. Did you ever provide financial support for a child’s routine immunization? 350 (76.1) 110 (23.9)
4. Did you ever discuss with your partner the child’s routine immunization schedule? 266 (57.8) 194 (42.2)
5. Did you ever make a decision with partner to have the child routinely immunized? 195 (42.4) 265 (57.6)
29% (132/460) of fathers were highly involved in RCI (participated in 4-5 indices)
Table 2: Level of male involvement in routine child immunization

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those with a positive attitude towards involvement. Men
engaged in trade as the main occupation were less
involved.
Variable Total
n=460
High
involvement
no. (%).
n=132
Low
involvement
no. (%).
n=328
Unadjusted
PRR (95% CI)
Adjusted
PRRc (95% CI)
Age
18-24 74 13 (17.6) 61 (82.4) 1 1
25-34 236 72 (30.5) 164 (69.5) 1.74 (1.02 - 2.95) 1.59 (0.53 - 2.72)
35-44 98 29 (29.6) 69 (70.4) 1.68 (0.94 - 3.01) 1.58 (0.88 - 2.84)
≥45 years 52 18 (34.6) 34 (65.4) 1.97 (1.06 - 3.66) 2.00 (1.15 - 3.76)*
Formal educational level
≤7 years in school 236 60 (25.4) 174 (74.6) 1 1
≥8 years in school 224 72 (32.1) 152 (67.9) 1.26 (0.95 - 1.69) 1.33 (0.98 – 1.81)
Occupation
Farmer 190 63 (33.2) 127 (66.8) 1 1
Casual laborer 83 22 (26.5) 61 (73.5) 0.80 (0.53 - 1.21) 0.86 (0.57 - 1.30)
Trader 135 25 (18.5) 110 (81.5) 0.56 (0.37 - 0.84) 0.55 (0.37- 0.82)**
Formally employed 52 22 (43.2) 30 (57.8) 1.28 (0.88 - 1.86) 1.00 (0.66 - 1.50)
Number of children
≤4 353 29 (8.2) 250 (70.8) 1
>4 107 103 (96.3) 78 (72.9) 0.93 (0.65 -1.32)
Sex of the child
Male 222 60(27.0) 162 (73.0) 1
Female 238 72 (30.3) 166 (69.7) 1.12 (0.84 - 1.49)
Attitudea
Male involvement in RCI is beneficial to the child
Yes 401 122 (30.4) 279 (69.6) 1.79 (1.00 - 3.22) 1.08 (0.60 - 1.95)
No 59 10 (16.9) 49 (83.1) 1 1
RCI is equally a man’s role
Yes 310 103 (33.2) 207 (66.8) 1.72 (1.19 - 2.47) 1.19 (0.77 - 1.84)
No 150 29 (19.3) 121 (80.7) 1 1
I am willing to be involved
in RCI
Yes 415 128 (30.8) 287 (69.2) 3.47 (1.35- 8.95) 3.17 (1.27- 7.92)
No 45 4(8.9) 41 (91.1) 1 1
I can recommend another man to be involved in RCI care
Yes 405 124 (30.6) 281 (69.4) 2.10 (1.09 - 4.06) 1.16 (0.46 - 2.93)
No 55 8 (14.5) 47 (85.5) 1 1
Table 3: Factors associated with male involvement in routine child immunization
Overall attitude
Positive (yes to 3-4 indices) 399 125 (31.3) 274 (68.7) 2.73 (1.34 - 5.57) 2.31 (1.18 - 4.98)*
Negative (yes to ≤2 indices) 61 7 (11.5) 54 (88.5) 1 1
Social influence
Perceived gender roles in
RCI
Joint parental role 112 44 (33.3) 68 (20.7) 1 1
Man’s role 14 3 (2.3) 11 (3.4) 0.55 (0.19 - 1.53) 0.72 (0.29 - 1.95)
Mother’s role 334 85 (64.4) 249 (75.9) 0.65 (0.48 -0.87) 1.39 (0.96 - 1.75)

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Lower levels of male involvement have been
reported in other child health programs such as the
prevention of mother-to-child transmission of HIV
(PMTCT) programmes in Uganda [20, 23] and Tanzania
[24]. The lack of male involvement is prohibitive for
successful child health programs [20, 23], and is often
related to the influence of hierarchy and power between
men and women which underlies several aspects of
decision making for health [3, 16, 25] Studies have
indicated that most women cannot make the decision to
have the child immunized alone and that some husbands
refuse permission, especially if the child has previously
developed vaccine side effects [3, 8]. A woman’s lack of
decision-making autonomy has been associated with a
lower likelihood of fully immunizing the child [18].
Therefore implementation of strategies that increase
male involvement in RCI cannot be overemphasized.
In our study, a man's positive attitude towards
involvement in RCI was associated with high
involvement in RCI similar to findings from an urban
Ugandan setting where attitude was the strongest
predictor of health seeking behavior among men [26].
Earlier studies show that an individual’s intention and
willingness to undertake a preventive health behavior
increases when they have a positive evaluation of the
behavior [14, 26, 27]. The majority of respondents in
our study considered involvement in RCI as beneficial.
Variable Total
n=460
High
involvement
no. (%).
n=132
Low
involvement
no. (%).
n=328
Unadjusted
PRR (95% CI)
Adjusted
PRRc (95% CI)
Ever encouraged to be involved in RCI
Yes 325 101 (31.1) 224 (68.9) 1.35 (0.95 - 1.92) 1.18 (0.86 – 1.64)
No 135 31 (23.0) 104 (77) 1 1
Ever discouraged to be involved in RCI
Yes 106 32 (30.2) 74 (69.8) 1.07 (0.76 - 1.49) 1.14 (0.80 – 1.62)
No 353 100 (28.3) 253 (71.7) 1 1
Self efficacyb
I do not mind long waiting times at the immunization
clinic
Yes 258 85 (32.9) 173 (67.1) 1.42 (1.04 - 1.92) 1.21 (0.90 - 1.63)
No 202 47 (23.3) 155 (76.7) 1 1
I can ignore ridicule from peers to be involved in RCI
Yes 348 107 (30.7) 241 (69.3) 1.38 (0.94 - 2.01) 1.10 (0.66 - 1.51)
No 112 25 (22.3) 87 (77.7) 1 1
I can ignore gender roles to be involved in RCI
Yes 321 96 (29.9) 225 (70.1) 1.15 (0.83 - 1.60)
No 139 36 (25.9) 103 (74.1) 1
I can forego work to take child or accompany partner for RCI
Yes 306 96 (31.4) 210 (68.6) 1.34 (0.96 - 1.87) 0.93 (0.65 - 1.35)
No 154 36 (23.4) 118 (76.6) 1 1
I can use some money to be involved in RCI
Yes 395 117 (29.6) 278 (70.4) 1.28 (0.80 - 2.05)
No 65 15 (23.1) 50 (76.9) 1
I do not mind the long distance to the immunization
clinic
Yes 362 107 (29.6) 225 (70.4) 1.16 (0.79 - 1.68)
No 98 25 (25.5) 73 (74.5) 1
Overall self efficacy
High (yes to 4-5 SE factors) 333 104(31.2) 229 (68.8) 1.42 (0.98 - 2.04) 1.13 (0.78 - 1.63)
Low (yes to ≤3 SE factors) 127 28(22.0) 99 (78.0) 1 1
Table 3 Continued...

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Therefore strategies that emphasize the benefits of
men's involvement such as opportunity for child health
care education, the importance of timely RCI schedule
completion, the associated child health and economic
gains of RCI would strengthen men's positive attitude
towards involvement in RCI in this setting.
Older fathers were more involved in routine
child immunization consistent with earlier findings from a
high income setting [28]. It is possible that older men in
our study setting have previously experienced firsthand
the devastating health effects of vaccine preventable
diseases (VPDs) among infants compared to the younger
generation that has joined fatherhood in the era with
reduced occurrence of VPDs [3, 29]. In addition, the
benefits of child vaccination activities are not
immediately apparent to child caretakers, thus there is
little motivation especially among the younger fathers to
prioritize vaccination services amidst competing
demands for time [30].
Men whose main occupation was trade were
significantly associated with lower involvement in RCI.
Similar to findings from a PMTCT program in Eastern
Uganda where men involved in occupations that kept
them away from home for long hours were less involved
in their child's health care [20]. The long waiting times
known to prevail during child health activities could have
hindered this category of men from participating in child
health programs [2]. In addition, the gender role
demarcations reported by most of our respondents act
as a barrier to male involvement in their children’s
health [3, 25]. Moreover, the systems in place at many
health facilities are oriented toward women to the extent
that they have become institutional barriers to greater
male involvement [3, 24, 25]. Nearly all men in our
study expressed willingness to participate in RCI. The
role of men therefore needs to move beyond an
ancillary, supportive position and become one that
strengthens the link between mother, child and the
health system [9, 25].
Methodological considerations
Our study developed a composite measure of
male involvement using questions from published
literature. The composite measure used here gives a
broader understanding of indicators which interact in a
complex manner to influence male involvement in RCI.
In contrast, a few studies done on male involvement in
RCI have used a single involvement indicator to measure
male involvement [28, 31]. Another strength in this
study is that survey participants were selected within the
community, essentially eliminating the selection bias that
could have arisen if the participants were obtained at
immunisation facilities. Finally, the ASE model has been
useful in this study for examining factors associated with
male involvement in this setting. However, self-efficacy
factors were not statistically associated with male
involvement. This deviation from the general precepts of
the ASE model could be due to the “intention-behavior
gap” described for ASE models [26]. Thus, although
nearly all men were willing to participate in RCI only a
third of them were involved to a satisfactory level. In
addition, an individual's perceived and actual abilities to
undertake the behavior should be measured in order to
estimate self-efficacy; only perceived ability was
measured for this study. Future studies should consider
both aspects in measurement of self-efficacy.
Conclusions
This study used five indicators to measure male
involvement in routine child immunization (RCI) differing
from other reports that use only one of the five
indicators for male involvement. Overall, a small
proportion of fathers were involved in RCI in this rural
setting. And several factors associated with their
involvement have been identified. For instance, men's
positive attitude towards involvement in RCI was
associated with higher male involvement. Interventions
to improve men's attitude such as health education or
peer education are needed to increase their
involvement. These interventions need to be centered

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on the involvement of both parents in the health care of
the family, in conjunction with local and policy-level
changes that support an environment more conducive to
men’s participation [25]. Younger fathers and men with
occupations that keep them away from home such as
traders could be the primary target of these
interventions.
Acknowledgments
This study was funded by the United States
Agency for International Development (USAID) through
AFENET/USAID/CDC Trainee Grants Program to improve
immunization coverage, number AFE2012 RS-01. The
funding agency was not involved in any of the research
activities or in the writing of the manuscript. We thank
the study participants, the research assistants, local
council leaders, and the District Health Team.
Conflict of Interest
The authors have declared that no competing
interest exist.
Author Contributions
Conceived and designed the experiments: CB
JNB PO LA. Performed the experiments: CB JNB PO.
Analyzed the data: CB JNB PO PW LA. Contributed
reagents/materials/analysis tools: CB JNB PO PW LA.
Wrote the paper: CB JNB PO PW LA.
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